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entitled 'Hurricane Katrina: Federal Grants Have Helped Health Care
Organizations Provide Primary Care, but Challenges Remain' which was
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Report to Congressional Requesters:
United States Government Accountability Office:
GAO:
July 2009:
Hurricane Katrina:
Federal Grants Have Helped Health Care Organizations Provide Primary
Care, but Challenges Remain:
GAO-09-588:
GAO Highlights:
Highlights of GAO-09-588, a report to congressional requesters.
Why GAO Did This Study:
The greater New Orleans area—Jefferson, Orleans, Plaquemines, and St.
Bernard parishes—continues to face challenges in restoring health care
services disrupted by Hurricane Katrina. In 2007, the Department of
Health and Human Services (HHS) awarded the $100 million Primary Care
Access and Stabilization Grant (PCASG) to Louisiana to help restore
primary care services to the low-income population. Louisiana gave
PCASG funds to 25 outpatient provider organizations in the greater New
Orleans area. GAO was asked to study how the federal government can
effectively leverage governmental resources to help area residents gain
access to primary care services. This report examines (1) how PCASG
fund recipients used the PCASG funds to support primary care services
in greater New Orleans, (2) how PCASG fund recipients used and
benefited from other federal hurricane relief funds that support the
restoration of primary care services in the area, and (3) challenges
PCASG fund recipients continued to face in providing primary care, and
their plans for sustaining services after PCASG funds are no longer
available.
To conduct this work, GAO analyzed responses to a GAO survey sent to
all PCASG fund recipients, to which 23 of the 25 recipients responded,
and reviewed and analyzed information related to other federal funds
received by PCASG fund recipients. GAO also conducted site visits at 8
recipients and interviewed federal and state officials and other
experts.
What GAO Found:
PCASG fund recipients reported that they used the PCASG funds to hire
or retain health care providers and other staff, add primary care
services, and open new sites. For example, 20 of the 23 recipients that
responded to the GAO survey reported using PCASG funds to hire health
care providers, and 17 reported using PCASG funds to retain health care
providers. In addition, most of the recipients reported that they used
PCASG funds to add primary care services and to add or renovate sites.
Recipients also reported that the grant requirements and funding helped
them improve service delivery and expand access to care in underserved
neighborhoods.
Other federal hurricane relief funds helped PCASG fund recipients pay
staff, purchase equipment, and expand mental health services to help
restore primary care. Eleven recipients received HHS Social Services
Block Grant (SSBG) supplemental funds designated by Louisiana for
primary care, and two received SSBG supplemental funds designated by
Louisiana specifically for mental health care. The funds designated for
primary care were used to pay staff and purchase equipment, and the
funds designated for mental health care were used to provide a range of
services for adults and children, including crisis intervention and
substance abuse prevention and treatment. About two-thirds of the PCASG
fund recipients benefited from the Professional Workforce Supply Grant
incentives. These recipients hired or retained 69 health care providers
who received incentives totaling over $4 million to work in the greater
New Orleans area. In addition, one PCASG fund recipient expended $7.9
million it received from Louisiana to provide services through the
federal Crisis Counseling Assistance and Training Program.
PCASG fund recipients continue to face multiple challenges and have
various plans for sustainability. Recipients face significant
challenges in hiring and retaining staff, as well as in referring
patients outside of their organizations, and these challenges have
grown since Hurricane Katrina. For example, 20 of 23 recipients that
responded to the GAO survey reported hiring was a great or moderate
challenge, and among these 20 recipients over three-quarters reported
that this challenge had grown since Hurricane Katrina. Six of the 7
recipients that primarily provide mental health services reported that
both hiring and retention of providers were great or moderate
challenges. Many PCASG fund recipients also reported challenges in
referring patients outside their organization for mental health,
dental, and specialty care services. Although all PCASG fund recipients
have completed or planned actions to increase their ability to be
sustainable, it is too early to know whether their various
sustainability strategies will be successful.
HHS reviewed a draft of this report and provided technical comments,
which GAO incorporated as appropriate.
View [hyperlink, http://www.gao.gov/products/GAO-09-588] or key
components. For more information, contact Cynthia A. Bascetta at (202)
512-7114 or bascettac@gao.gov.
[End of section]
Contents:
Letter:
Background:
PCASG Fund Recipients Used PCASG Funds to Support Primary Care Services
by Hiring Health Care Providers and Other Staff and Adding Services and
Sites:
Other Federal Hurricane Relief Funds Helped PCASG Fund Recipients to
Pay Staff, Purchase Equipment, and Expand Mental Health Services to
Help Restore Primary Care:
PCASG Fund Recipients Face Multiple Challenges and Have Various Plans
for Sustainability:
Agency Comments:
Appendix I: Scope and Methodology:
Appendix II: Primary Care Access and Stabilization Grant Fund
Recipients: Characteristics, Patients, and Services:
Appendix III: GAO Contact and Staff Acknowledgments:
Related GAO Products:
Tables:
Table 1: Estimated Annual Population of the Greater New Orleans Area,
by Parish, as of July 1, 2005, and July 1, 2008:
Table 2: Number of Primary Care Access and Stabilization Grant (PCASG)
Fund Recipients That Used PCASG Funds to Add or Expand Services, by
Service Type, as of October 28, 2008:
Table 3: Primary Care Access and Stabilization Grant (PCASG) Fund
Recipients' Expenditures of Social Services Block Grant (SSBG)
Supplemental Funds Designated for Primary Care, through August 2008:
Table 4: Amounts and Percentages of Social Services Block Grant
Supplemental Funds Designated for Mental Health Care That Were Expended
by Primary Care Access and Stabilization Grant Fund Recipients, by Type
of Service, as of March 3, 2009:
Table 5: Health Care Providers Who Received Professional Workforce
Supply Grant Incentive Payments and Were Employed by Primary Care
Access and Stabilization Grant (PCASG) Fund Recipients, by Provider
Type, through August 2008:
Table 6: Selected Characteristics of Primary Care Access and
Stabilization Grant (PCASG) Fund Recipients, September 21, 2007,
through March 20, 2008:
Figures:
Figure 1: Timeline of Health-Care-Related Federal Grants Assisting the
Greater New Orleans Area Since Hurricane Katrina:
Figure 2: Number of Primary Care Access and Stabilization Grant (PCASG)
Fund Recipients That Used PCASG Funds to Hire Health Care Providers, as
of October 28, 2008:
Figure 3: Ratings by Primary Care Access and Stabilization Grant
(PCASG) Fund Recipients of Challenges to Providing Primary Care
Services, and Comparison with Period Prior to Hurricane Katrina:
Figure 4: Primary Care Access and Stabilization Grant (PCASG) Fund
Recipients' Patient Population, by Health Insurance Status, September
21, 2007, through March 20, 2008:
Figure 5: Encounters at Primary Care Access and Stabilization Grant
(PCASG) Fund Recipients, by Service Type, September 21, 2007, through
March 20, 2008:
Abbreviations:
ACF: Administration for Children and Families:
CCP: Crisis Counseling Assistance and Training Program:
CMS: Centers for Medicare & Medicaid Services:
FEMA: Federal Emergency Management Agency:
FQHC: Federally Qualified Health Center:
HHS: Department of Health and Human Services:
HPSA: health professional shortage area:
HRSA: Health Resources and Services Administration:
JPHSA: Jefferson Parish Human Services Authority:
LaCHIP: Louisiana Children's Health Insurance Program:
LDHH: Louisiana Department of Health and Hospitals:
LDSS: Louisiana Department of Social Services:
LPHI: Louisiana Public Health Institute:
LSU: Louisiana State University:
MCLNO: Medical Center of Louisiana at New Orleans:
MHSD: Metropolitan Human Services District:
PCASG: Primary Care Access and Stabilization Grant:
SAMHSA: Substance Abuse and Mental Health Services Administration:
SSBG: Social Services Block Grant:
[End of section]
United States Government Accountability Office:
Washington, DC 20548:
July 13, 2009:
The Honorable Joseph I. Lieberman:
Chairman:
Committee on Homeland Security and Governmental Affairs:
United States Senate:
The Honorable Mary L. Landrieu:
Chairman:
Ad Hoc Subcommittee on Disaster Recovery:
Committee on Homeland Security and Governmental Affairs:
United States Senate:
Nearly 4 years after Hurricane Katrina, the greater New Orleans area
continues to face challenges in restoring health care services
disrupted by the storm.[Footnote 1] Before the hurricane, the low-
income population in the area had relied on hospital emergency rooms
and outpatient clinics, mostly hospital-based, as its main source of
primary care.[Footnote 2] These clinics provided care to many patients
who were uninsured or covered by Medicaid.[Footnote 3] Following the
hurricane and the subsequent flooding, the hospitals and clinics closed
because of the significant damage they had sustained. As studies have
shown, disaster survivors continue to experience poor physical and
mental health for prolonged periods after the event.[Footnote 4] After
the hurricane, various health care provider organizations in the area
were able to reopen some health care clinics. However, gaps remained in
the availability of health care services in the greater New Orleans
area.
To help address the continuing health care needs of low-income area
residents, the Department of Health and Human Services (HHS) awarded
the $100 million Primary Care Access and Stabilization Grant (PCASG) to
the Louisiana Department of Health and Hospitals (LDHH) in July 2007.
[Footnote 5] The grant is administered at the federal level by HHS's
Centers for Medicare & Medicaid Services (CMS). It is intended to
restore and expand access to primary care services, including mental
health care services[Footnote 6] and dental care services, without
regard to a patient's ability to pay. The grant is also intended to
decrease costly reliance on emergency room use for primary care
services for patients who are uninsured, underinsured, or covered by
Medicaid. CMS required LDHH to use the grant to provide short-term
funding to outpatient provider organizations to help them take such
actions as increasing their staff, renovating clinics, and opening new
clinic sites. LDHH provided funds to 25 organizations--which we refer
to as PCASG fund recipients; as of March 20, 2008, the recipients were
operating 75 sites that were eligible to use PCASG funds.[Footnote 7]
The Louisiana Public Health Institute (LPHI) administers the PCASG for
LDHH and distributes grant funds as its local partner. For an
organization to be eligible for PCASG funding, it must have been a
public or private nonprofit organization serving patients in the
greater New Orleans area--which CMS defined as Jefferson, Orleans,
Plaquemines, and St. Bernard parishes--at the time that Louisiana's
grant proposal was submitted. It must also have had the intent to be
sustainable, that is, able to continue providing primary care after
PCASG funds are no longer available.[Footnote 8]
In addition to the PCASG, other federal grants were awarded following
Hurricane Katrina that could help support access to primary care
services. These include the Social Services Block Grant (SSBG)
supplemental funds from HHS's Administration for Children and Families
(ACF) and grants from the Crisis Counseling Assistance and Training
Program (CCP), which is administered by the Federal Emergency
Management Agency (FEMA) and its federal partner, HHS's Substance Abuse
and Mental Health Services Administration (SAMHSA).[Footnote 9]
Provider organizations also could benefit from CMS's Professional
Workforce Supply Grant, through which incentives were paid to
prospective or current employees. Grants from the Health Center Program
of HHS's Health Resources and Services Administration (HRSA) were also
available during this time to certain organizations providing primary
care services.
You asked us to study how the federal government can effectively
leverage governmental resources to help the victims of Hurricane
Katrina gain access to primary care services. In this report, we
examine (1) how PCASG fund recipients used the PCASG funds to support
the provision of primary care services in the greater New Orleans area,
(2) how PCASG fund recipients used and benefited from other federal
hurricane relief funds that support the restoration of primary care
services in the greater New Orleans area, and (3) challenges the PCASG
fund recipients continued to face in providing primary care services,
and recipients' plans for sustaining services after PCASG funds are no
longer available.
To determine how the PCASG fund recipients used PCASG funds to support
the provision of primary care services in the greater New Orleans area,
[Footnote 10] we conducted site visits at 8 of the 25 PCASG fund
recipients during April 2008. To identify the locations for our site
visits, we chose a selective sample of the recipients, including some
that offered mental health care services or dental care services and 2
that were Health Center Program grantees. In addition, we included at
least 1 recipient from each of the area's four parishes. During these
visits we collected documents and interviewed PCASG fund recipient,
state, and local officials. Based in part on information we gathered
during the site visits, we developed a Web-based survey. Our survey
focused on how recipients used PCASG funds, the challenges they
continued to face, and their plans for sustainability. Before we
disseminated the survey to the 25 recipients, the survey questions were
peer-reviewed by LPHI because of its expertise on the grant program. We
received responses from 23 of the 25 recipients, a response rate of 92
percent. Based on activities we conducted to assess the reliability of
the survey data, such as reviewing survey data for inconsistencies and
completeness, we determined that the data were sufficiently reliable
for the purposes of this report. We also reviewed the recipients'
applications for PCASG funding and interviewed officials at LDHH and
LPHI about how the recipients used PCASG funds.
To answer our question on how the PCASG fund recipients used and
benefited from other federal funds for hurricane relief, we identified
relevant funding sources that recipients used or benefited from, and we
examined the funding amounts and the ways the funds were used.
Specifically, we reviewed and analyzed data from LDHH on expenditures
related to the supplemental SSBG, on awards made under CMS's
Professional Workforce Supply Grant Program, and on the CCP. Through
assessments of internal consistency and verification with state and
local officials, we determined that these data were sufficiently
reliable for the purposes of this report. We also interviewed officials
at LDHH and PCASG fund recipients about these programs.
To answer our questions on challenges PCASG fund recipients continued
to face in providing primary care services and how the recipients
planned to sustain primary care services after PCASG funding is no
longer available, we used information collected from the Web-based
survey. We also analyzed interviews we conducted with 10 recipients,
including the 8 we visited, and with federal, state, and local agency
officials. In addition, we reviewed sustainability plans that the
recipients included in their applications for PCASG funding.
To provide additional information on the PCASG fund recipients, we used
data collected by LPHI on types of services that the recipients
offered. We also used patient and encounter data[Footnote 11] that LPHI
summarized for us. PCASG funds were not the only funds used to support
the services these data describe. Based on activities we conducted to
assess the reliability of these data, such as discussing with LPHI
officials their processes to establish the accuracy and reliability of
the data they gave us, we determined that the data were sufficiently
reliable for the purposes of our report.
We conducted our work from February 2008 through June 2009 in
accordance with all sections of GAO's Quality Assurance Framework that
are relevant to our objectives. The framework requires that we plan and
perform the engagement to obtain sufficient and appropriate evidence to
meet our stated objectives and to discuss any limitations in our work.
We believe that the information and data obtained, and the analysis
conducted, provide a reasonable basis for any findings and conclusions
in this product. See appendix I for more information about our scope
and methodology.
Background:
Since Hurricane Katrina, the population of the greater New Orleans area
has decreased, and the health care delivery system for the low-income
and uninsured population in the area has begun to change from one that
was largely hospital-based to a more community-based system of primary
care. Since the disruption to the health care system caused by the
hurricane, several federal agencies have awarded grants that facilitate
access to primary care.
Greater New Orleans Area Population:
The estimated population of the greater New Orleans area decreased from
999,349 in July 2005 to 807,032 in July 2008, a level of about 81
percent of the population before Hurricane Katrina. Most of the
decrease in population was in Orleans and St. Bernard parishes. (See
table 1.)
Table 1: Estimated Annual Population of the Greater New Orleans Area,
by Parish, as of July 1, 2005, and July 1, 2008:
Parish: Jefferson;
Estimated annual population as of July 1, 2005: 450,848;
Estimated annual population as of July 1, 2008[A]: 436,181.
Parish: Orleans;
Estimated annual population as of July 1, 2005: 455,046;
Estimated annual population as of July 1, 2008[A]: 311,853.
Parish: Plaquemines;
Estimated annual population as of July 1, 2005: 28,565;
Estimated annual population as of July 1, 2008[A]: 21,276.
Parish: St. Bernard;
Estimated annual population as of July 1, 2005: 64,890;
Estimated annual population as of July 1, 2008[A]: 37,722.
Parish: Total;
Estimated annual population as of July 1, 2005: 999,349;
Estimated annual population as of July 1, 2008[A]: 807,032.
Source: U.S. Census Bureau.
[A] The July 2008 estimate was the most recent estimate available at
the time we did our work.
[End of table]
Health Care Delivery in the Greater New Orleans Area:
Before Hurricane Katrina, most health care for the low-income and
uninsured population in the greater New Orleans area was provided in
emergency rooms and outpatient clinics at Charity and University
hospitals, which together were known as the Medical Center of Louisiana
at New Orleans (MCLNO). MCLNO is part of Louisiana State University's
(LSU) statewide system of public hospitals. About half of MCLNO's
patients were uninsured, and about one-third were covered by Medicaid.
As a result of damage from Hurricane Katrina and the subsequent
flooding, Charity and University hospitals were closed. In November
2006, LSU reopened University Hospital, under its new, temporary name,
Interim LSU Public Hospital. Charity Hospital remained closed as of
June 2009.
In addition to the hospital outpatient clinics, other types of clinics
provided primary care, including mental health care, for the low-income
and uninsured population before Hurricane Katrina. These included
health centers participating in HRSA's Health Center Program. Under
Section 330 of the Public Health Service Act, HRSA provides grants to
health centers nationwide to increase access to primary care.[Footnote
12] HRSA uses a competitive process to award grants, including New
Access Point grants for new grantees or for existing grantees to
establish additional sites. Existing grantees may also compete for
Expanded Medical Capacity grants to increase service capacity, such as
by expanding operating hours, or Service Expansion grants to add or
expand services, such as mental health, oral health, and pharmacy
services.
All health center grantees are Federally Qualified Health Centers
(FQHC), which enjoy certain federal benefits such as enhanced Medicare
and Medicaid payment rates. However, not all FQHCs receive Health
Center Program grants, and those that do not are sometimes referred to
as having an FQHC Look-Alike designation. Four health center grantees
served the greater New Orleans area at the time HHS awarded the PCASG
in July 2007.
In 2007, Louisiana enacted the Health Care Reform Act of 2007, which
directed LDHH to develop and implement a new health care delivery
system for the state's Medicaid recipients and low-income uninsured
citizens.[Footnote 13] LDHH proposed short-term and long-term
recommendations,[Footnote 14] which included changes to the Louisiana
Children's Health Insurance Program (LaCHIP) in 2008 to expand coverage
to more children.[Footnote 15] LDHH also submitted a demonstration
waiver application to CMS for its Medicaid program to expand coverage
and create a coordinated system of care.[Footnote 16]
Federal Assistance to Restore Access to Primary Care:
In response to Hurricane Katrina, several federal agencies provided
grants that assist with the restoration of primary care in the greater
New Orleans area. (See figure 1.) FEMA provided CCP funds to Louisiana
for certain mental health services. ACF provided supplemental SSBG
funds for primary health care services, among other things. In
addition, CMS provided Professional Workforce Supply Grant funds to
reduce health care provider shortages and PCASG funds to restore access
to primary care.
Figure 1: Timeline of Health-Care-Related Federal Grants Assisting the
Greater New Orleans Area Since Hurricane Katrina:
[Refer to PDF for image: timeline]
Hurricane Katrina: August 2005;
Hurricane Rita: September 2005;
FENMA & SAMHSA’s Crisis Counseling Assistance and Training Program:
$29 million[A] (August 2005 – December 2008);
ACF’s Social Services Block Grant Supplemental: $168 million[B]
(February 2006 – September 2007, extended to September 2009);
CMS’s Professional Workforce Supply Grant: $50 million[C] (March 2007 –
September 2009)[D];
CMS’s Primary Care Access and Stabilization Grant: $100 million[C]
(July 2007 – September 2010).
Note: End dates represent the dates after which funds will no longer be
available according to the original grant, unless otherwise indicated.
[A] Dollar amount is for amount of grant funds awarded to Louisiana
that Louisiana distributed in the greater New Orleans area. In December
2008, Louisiana was awarded an additional $2.8 million in Crisis
Counseling Assistance and Training Program funds for services related
to Hurricane Gustav, which struck New Orleans in September 2008.
[B] Dollar amount is amount of Social Services Block Grant (SSBG)
supplemental funds awarded to Louisiana that the state dedicated to
health care. In January 2009, nearly $130 million in additional SSBG
supplemental funds was awarded to Louisiana for continued recovery from
Hurricanes Katrina, Rita, Gustav, and Ike (which struck New Orleans in
September 2008). The Louisiana Department of Social Services issued an
initial proposal that would allocate nearly $95 million of the 2009
SSBG supplemental funds to health care services, although not all of
that would be spent in the greater New Orleans area.
[C] Dollar amount is for grants awarded to Louisiana for the greater
New Orleans area.
[D] CMS's Professional Workforce Supply Grant may end earlier if all
incentive payments are made prior to September 2009.
[End of figure]
Crisis Counseling Assistance and Training Program Grants:
The CCP provided funds for crisis counseling services--including stress
reduction and coping education, community outreach, individual and
group crisis counseling, and referral for other services--to Louisiana.
The state subsequently distributed $29 million of these funds in the
greater New Orleans area.[Footnote 17] The CCP was designed to meet the
short-term mental health needs of people affected by disasters. State
officials told us that, generally, the CCP allows a person to have
three to five counseling visits but does not provide for a traditional
mental health diagnostic assessment and cannot be used for traditional
mental health or substance abuse services. CCP grantees may, however,
provide information to families and individuals about available mental
health and substance abuse services. Additional assistance may be
available to certain families through the Louisiana CCP's Specialized
Crisis Counseling Services.
Social Services Block Grant:
ACF administers SSBG funding to assist states in delivering social
services, which generally do not include health care services. In 2006,
however, Congress appropriated emergency SSBG supplemental funding that
could be spent on, among other things, health care services.[Footnote
18] From this appropriation, ACF awarded more than $220 million to
Louisiana. The Louisiana Department of Social Services (LDSS) served as
the state-level administrator and collaborated with LDHH and the Office
of the Governor to develop a spending plan that dedicated about $168
million of this amount for resuming and restoring health care services.
LDHH received $101.7 million, which it divided into two service
categories. First, LDHH designated $80 million specifically for mental
health care, including substance abuse and developmental disability
services, to meet the emerging mental health crisis. Second, LDHH
designated $21.7 million for primary care, which could include mental
health care, to restore and resume services to meet the health care
needs of people affected by the hurricanes. The primary care funds were
intended to target the southernmost parishes and regions that had
experienced a devastating blow to their primary care infrastructure.
Each local parish could develop a proposal for restoring services its
population needed and for responding to the challenges it faced in
rebuilding its basic health care system.
LDSS awarded the remaining health care services funds directly to LSU
Health Sciences Center and Tulane University Health Sciences Center.
Louisiana has until September 30, 2009, to spend these funds, which are
distributed as reimbursements after services are delivered.[Footnote
19]
LDHH distributed the mental health funds to various offices in the
department and to the state's four regional human services
districts,[Footnote 20] which then contracted with various individuals
and organizations to provide some of the services. A state official
told us that the mental health funds were available statewide in part
because many people from the greater New Orleans area who needed mental
health services following the hurricanes were dispersed throughout the
state.
Professional Workforce Supply Grant:
The $50 million Professional Workforce Supply Grant was awarded by the
Secretary of HHS in March 2007.[Footnote 21] The purpose of the grant
was to reduce shortages in the professional health care workforce
following Hurricane Katrina, and CMS gave Louisiana flexibility to
design its program within broad federal guidelines.[Footnote 22] LDHH,
which administers the grant, used the funds to create and fund the
Greater New Orleans Health Service Corps, which recruits individual
health care providers for health care organizations by offering
incentive payments to the individuals. Incentive amounts are based on
an individual's medical specialty and range from $10,000 to $110,000.
To be eligible, a health care provider must, among other things, agree
to serve Medicare, Medicaid, and uninsured patients; have a sliding fee
scale; and provide services in a federally designated health
professional shortage area (HPSA). Health care providers are also
expected to enter into an agreement with LaCHIP to provide services to
children enrolled in that program, if appropriate. Financial incentive
payments can be given to health care providers who remain in their
qualifying job or to newly hired health care providers; individuals may
receive only one financial incentive payment.
Primary Care Access and Stabilization Grant:
In July 2007, CMS awarded the PCASG to LDHH, which selected LPHI as the
local partner responsible for administering the grant program. The
PCASG was established by HHS under the authority of the Deficit
Reduction Act of 2005, which allowed HHS to allocate funds to restore
access to health care in communities affected by Hurricane Katrina, and
to provide funds for other services, such as those provided by Medicaid
and the State Children's Health Insurance Program.[Footnote 23] The
greater New Orleans area was targeted to receive PCASG funds because of
the unique impact Hurricane Katrina and its resulting floods had on the
area.
LDHH and LPHI determined that 25 organizations met the PCASG
requirements that CMS established, and they were all awarded funding.
[Footnote 24] The 25 organizations varied in size and other
characteristics. For example, some recipients are affiliated with an
institution such as a university or state or local government, and some
are grantees of HRSA's Health Center Program. (For more information on
the characteristics of the PCASG fund recipients, see appendix II). In
addition to primary care services--medical, mental health, and dental
care services--PCASG fund recipients could use grant funds to provide
specialty care, such as cardiology and podiatry services, and ancillary
services, including supporting services such as translation, health
education, transportation, and outreach. After being awarded PCASG
funding, outpatient provider organizations had to meet several CMS
requirements, including creating referral relationships with local
specialists and hospitals, establishing a quality assurance or
improvement program, and providing a long-term sustainability plan.
[Footnote 25]
LPHI is responsible for distributing funds to PCASG fund recipients,
including an initial disbursement and five supplemental disbursements.
These are lump sum payments and are not reimbursement for individual
services provided. The 25 recipients received initial disbursements
totaling $17 million.[Footnote 26] The supplemental disbursements are
to be made over the grant period.[Footnote 27] CMS requires that more
of the funds be disbursed during the early part of the grant period and
that funding decline over the 3 years to ensure that recipients do not
rely primarily on PCASG funds for their continued operation and
sustainability.
LDHH and CMS provide oversight of the PCASG program. LDHH oversees the
work performed by LPHI, conducts site visits at PCASG fund recipients,
reviews budgets for LPHI and recipients, reviews and approves payments
to recipients, and determines whether to approve recipients' requests
to renovate sites. CMS visits recipients to observe their operations
and reviews reports from LDHH and LPHI in collaboration with officials
from other HHS agencies. Although the PCASG does not include a
requirement for a program evaluation, a private foundation is scheduled
to evaluate the PCASG program, and CMS officials plan to review and
approve this evaluation before it is published.[Footnote 28]
PCASG Fund Recipients Used PCASG Funds to Support Primary Care Services
by Hiring Health Care Providers and Other Staff and Adding Services and
Sites:
PCASG fund recipients reported that they used PCASG funds to hire or
retain health care providers and other staff, add primary care
services, and open new sites. Recipients also said that the PCASG funds
have helped them improve service delivery and access to care.
Almost All PCASG Fund Recipients That Responded to Our Survey Used
PCASG Funds to Hire or Retain Health Care Providers and Other Staff:
Most of the PCASG fund recipients that responded to our survey reported
they used PCASG funds to hire health care providers or other staff.
Twenty of the 23 responding recipients reported using PCASG funds to
hire health care providers. (See figure 2.)
Figure 2: Number of Primary Care Access and Stabilization Grant (PCASG)
Fund Recipients That Used PCASG Funds to Hire Health Care Providers, as
of October 28, 2008:
[Refer to PDF for image: illustration]
Medical health care providers: 4 recipients reported hiring only
medical health care providers;
Mental health care providers: 6 recipients reported hiring only mental
health care providers;
Medical and mental health care providers: 10 recipients reported hiring
both medical and mental health care providers.
Source: GAO analysis of PCASG fund recipients’ responses to GAO’s Web-
based survey.
Note: The data in the figure are based on the responses of the 23
recipients that responded to GAO's Web-based survey.
[End of figure]
Sixteen recipients hired mental health care providers, including mental
health counselors and psychiatrists. One recipient reported that by
hiring one psychiatrist, it could significantly increase clients'
access to services by cutting down a clinic's waiting list and by
providing clients with a "same-day" psychiatric consultation or
evaluation. Fourteen of the recipients responded they used PCASG funds
to hire medical care providers. One recipient reported that it hired 23
medical care providers, some of whom were staffed at its new sites.
Eighteen of the 23 PCASG fund recipients that responded to our survey
reported they used PCASG funds to hire other staff, such as a medical
director and a medical office assistant, in addition to hiring health
care providers. Some recipients reported that the ability to hire
providers enabled them to expand the hours some of their sites were
open.
PCASG fund recipients responded that in addition to hiring health care
providers and other staff, they also used PCASG funds to retain health
care providers and other staff. Of the 23 recipients that responded to
our survey, 17 reported they used PCASG funds to retain health care
providers, and 15 of these reported that they also used grant funds to
retain other staff. For example, one recipient reported that PCASG
funds were used to stabilize positions that were previously supported
by disaster relief funds and donated services.
A Large Proportion of PCASG Fund Recipients Used PCASG Funds to Add
Services and to Add or Renovate Sites:
Nineteen of the 23 PCASG fund recipients that responded to our survey
reported using PCASG funds to add or expand medical, mental health, or
dental care services, and more than half of these added or expanded
more than one type of service. (See table 2.)
Table 2: Number of Primary Care Access and Stabilization Grant (PCASG)
Fund Recipients That Used PCASG Funds to Add or Expand Services, by
Service Type, as of October 28, 2008:
Service type: Medical care;
Number of PCASG fund recipients: 11.
Service type: Mental health care;
Number of PCASG fund recipients: 15.
Service type: Dental care;
Number of PCASG fund recipients: 4.
Source: GAO analysis of PCASG fund recipients' responses to GAO's Web-
based survey.
Notes: The data in the table are based on the responses of the 23
recipients that responded to GAO's Web-based survey. Recipients may
have added or expanded more than one type of service.
[End of table]
PCASG fund recipients also reported using grant funds to add or expand
specialty care services or to add ancillary services. Eight recipients
added or expanded specialty care services. For example, one of these
recipients reported that it added podiatry services. The ancillary
services that recipients used grant funds to add included health
education, transportation, and outreach activities. One recipient
reported that it used PCASG funds to create a television commercial
announcing that a clinic was open and that psychiatric services were
available there, including free care for those who qualified
financially.
Almost all of the PCASG fund recipients that responded to our survey
reported they used PCASG funds for their physical space. Fifteen
recipients used the funds to open new sites or relocate sites.[Footnote
29] One of these recipients reported that it relocated to a larger
site, which allowed providers to have additional examination rooms. Ten
recipients reported using grant funds to renovate existing
sites.[Footnote 30] Some of these recipients made renovations--such as
expanding a waiting room, adding a registration window, and adding
patient restrooms--to accommodate more patients.
PCASG Fund Recipients Reported That Program Requirements and Funding
Have Improved Service Delivery and Access:
PCASG fund recipients that responded to our survey reported that
certain program requirements have had a positive effect on their
delivery of primary care services. Almost three-quarters of responding
recipients reported a requirement that they develop a network of local
specialists and hospitals for patient referrals has had a positive
effect. Similarly, over two-thirds of the responding recipients
reported that the requirement to establish a quality assurance and
improvement program, which must include developing clinical guidelines
or evidence-based standards of care, has had a positive effect on the
provision of primary care within their organization.[Footnote 31]
Various PCASG fund recipients have stated that PCASG funds helped them
improve access to health care services for residents of the greater New
Orleans area. One recipient reported to LPHI that PCASG funds allowed
it to expand its services beyond residents in its shelter and housing
programs to include community residents who were not homeless but
previously lacked access to health care services. Representatives of
other recipients have publicly stated that their organization improved
access to health care by expanding services in medically underserved
neighborhoods or to people who were uninsured or underinsured. In
addition, representatives of local organizations told us that the PCASG
provided an opportunity to rebuild the health care system and shift the
provision of primary care from hospitals to community-based primary
care clinics.
Other Federal Hurricane Relief Funds Helped PCASG Fund Recipients to
Pay Staff, Purchase Equipment, and Expand Mental Health Services to
Help Restore Primary Care:
PCASG fund recipients also used other federal hurricane relief funds to
provide services. They used SSBG supplemental funds designated by
Louisiana for primary care to pay for staff salaries and equipment, and
they used SSBG supplemental funds designated for mental health care to
provide a range of mental health services. PCASG fund recipients also
benefited from the Professional Workforce Supply Grant, which provided
incentives for health care providers, and one used funds from the CCP
to provide counseling services.
PCASG Fund Recipients That Received SSBG Supplemental Funds Designated
for Primary Care Used Them to Pay Salaries and Purchase Equipment:
Nearly half of PCASG fund recipients received SSBG supplemental funds
designated for primary care and used them to pay staff salaries,
purchase medical equipment, and support operations. According to LDHH
data, 11 PCASG fund recipients expended $12.9 million of the $21.7
million in SSBG supplemental funds awarded to Louisiana and designated
by the state for primary care, as of August 2008.[Footnote 32] After a
competitive process in 2006, LDHH distributed SSBG supplemental funds
ranging from $209,000 to over $2.6 million each to individual
recipients.[Footnote 33] (See table 3.) Officials from PCASG fund
recipient organizations that received these funds told us they had used
SSBG supplemental funds to pay salaries, purchase supplies and medical
equipment, and support their operations. For example, one recipient
used SSBG supplemental funds to hire new medical and support staff and,
as a result, expanded its services for mammography, cardiology, and
mental health. It also used SSBG supplemental funds to remodel the
associated examination rooms and lobby and to purchase operating
services, such as accounting services and insurance.
Table 3: Primary Care Access and Stabilization Grant (PCASG) Fund
Recipients' Expenditures of Social Services Block Grant (SSBG)
Supplemental Funds Designated for Primary Care, through August 2008:
PCASG recipient: Administrators of Tulane Educational Fund;
SSBG supplemental funds expended for primary care from February 2006
through August 2008 (dollars in thousands): $998.
PCASG recipient: City of New Orleans Health Department;
SSBG supplemental funds expended for primary care from February 2006
through August 2008 (dollars in thousands): $2,648.
PCASG recipient: Common Ground Health Clinic;
SSBG supplemental funds expended for primary care from February 2006
through August 2008 (dollars in thousands): $263.
PCASG recipient: Daughters of Charity Services of New Orleans;
SSBG supplemental funds expended for primary care from February 2006
through August 2008 (dollars in thousands): $1,188.
PCASG recipient: EXCELth, Inc.[A];
SSBG supplemental funds expended for primary care from February 2006
through August 2008 (dollars in thousands): $209.
PCASG recipient: Jefferson Community Health Care Centers, Inc.;
SSBG supplemental funds expended for primary care from February 2006
through August 2008 (dollars in thousands): $1,327.
PCASG recipient: LSU Health Sciences Center New Orleans (School Based
Health Centers);
SSBG supplemental funds expended for primary care from February 2006
through August 2008 (dollars in thousands): $244.
PCASG recipient: Plaquemines Medical Center;
SSBG supplemental funds expended for primary care from February 2006
through August 2008 (dollars in thousands): $1,227.
PCASG recipient: St. Bernard Health Center, Inc.;
SSBG supplemental funds expended for primary care from February 2006
through August 2008 (dollars in thousands): $2,439.
PCASG recipient: St. Charles Community Health Center - Kenner;
SSBG supplemental funds expended for primary care from February 2006
through August 2008 (dollars in thousands): $946.
PCASG recipient: St. Thomas Community Health Center;
SSBG supplemental funds expended for primary care from February 2006
through August 2008 (dollars in thousands): $1,398.
PCASG recipient: Total;
SSBG supplemental funds expended for primary care from February 2006
through August 2008 (dollars in thousands): $12,887.
Source: GAO analysis of Louisiana Department of Health and Hospitals
data.
Note: These SSBG supplemental funds were distributed by the Louisiana
Department of Health and Hospitals.
[A] EXCELth, Inc. received nearly $873,000 in additional SSBG
supplemental funds, which were expended at sites at which it did not
use PCASG funds.
[End of table]
In addition to distributing SSBG supplemental funds to LDHH for primary
care, LDSS distributed SSBG supplemental funds directly to one PCASG
recipient to support, in part, primary health care services.
Specifically, LSU Health Sciences Center New Orleans[Footnote 34]--
which also received SSBG supplemental funds for primary care from LDHH--
used $173,000 of the $33.5 million it received directly from LDSS to
pay for staff salaries and benefits at its PCASG sites.[Footnote 35]
Two PCASG Fund Recipients Used SSBG Supplemental Funds Designated for
Mental Health Care to Provide a Range of Services, Including Crisis
Intervention and Substance Abuse Prevention and Treatment:
The two PCASG fund recipients that received SSBG supplemental funds
designated for mental health care used them to provide crisis
intervention, substance abuse, and other mental health services. LDHH
distributed almost $12 million of the $80 million in SSBG supplemental
funds designated for mental health care to the two PCASG fund
recipients that are state regional human services districts--$4.3
million to Metropolitan Human Services District (MHSD) and $7.6 million
to Jefferson Parish Human Services Authority (JPHSA).[Footnote 36] MHSD
and JPHSA in turn distributed most of these funds through contracts to
other organizations and providers.[Footnote 37] They also retained a
portion of these funds to spend on the direct provision of mental
health care services or other expenses that were necessary for the
restoration of these services, such as minor repairs or replacement of
equipment and supplies. MHSD obligated $3.3 million under 30 contracts
and retained $1 million for direct expenses; JPHSA obligated $4.3
million under 80 contracts and retained nearly $3.4 million. Except for
just over $88,000 of JPHSA's funds, all $12 million had been expended
as of March 3, 2009.
LDHH identified five mental health care service categories for the use
of the SSBG supplemental funds. (See table 4.) Through March 3, 2009,
the largest portion of funds that MHSD expended was for the category
"substance abuse treatment and prevention." The largest portion of
funds that JPHSA expended was for the category "immediate intervention-
-crisis response," with the second largest portion expended for the
category "behavioral health services for children and adolescents."
[Footnote 38]
Table 4: Amounts and Percentages of Social Services Block Grant
Supplemental Funds Designated for Mental Health Care That Were Expended
by Primary Care Access and Stabilization Grant Fund Recipients, by Type
of Service, as of March 3, 2009:
Mental health care service areas: Immediate intervention - crisis
response;
Metropolitan Human Services District expenditures: Dollars in millions:
$0.8;
Metropolitan Human Services District expenditures: Percentage: 18;
Jefferson Parish Human Services Authority expenditures: Dollars in
millions: $2.9;
Jefferson Parish Human Services Authority expenditures: Percentage: 39.
Mental health care service areas: Substance abuse treatment and
prevention;
Metropolitan Human Services District expenditures: Dollars in millions:
$1.9;
Metropolitan Human Services District expenditures: Percentage: 43;
Jefferson Parish Human Services Authority expenditures: Dollars in
millions: $0.6;
Jefferson Parish Human Services Authority expenditures: Percentage: 9.
Mental health care service areas: Behavioral health services for
children and adolescents[A];
Metropolitan Human Services District expenditures: Dollars in millions:
$0.6;
Metropolitan Human Services District expenditures: Percentage: 14;
Jefferson Parish Human Services Authority expenditures: Dollars in
millions: $2.4;
Jefferson Parish Human Services Authority expenditures: Percentage: 31.
Mental health care service areas: Behavioral health program restoration
and resumption[A];
Metropolitan Human Services District expenditures: Dollars in millions:
$0.6;
Metropolitan Human Services District expenditures: Percentage: 14;
Jefferson Parish Human Services Authority expenditures: Dollars in
millions: $0.8;
Jefferson Parish Human Services Authority expenditures: Percentage: 11.
Mental health care service areas: Prevention or reduction of
inappropriate institutional care;
Metropolitan Human Services District expenditures: Dollars in millions:
$0.5;
Metropolitan Human Services District expenditures: Percentage: 12;
Jefferson Parish Human Services Authority expenditures: Dollars in
millions: $0.8;
Jefferson Parish Human Services Authority expenditures: Percentage: 10.
Mental health care service areas: Total;
Metropolitan Human Services District expenditures: Dollars in millions:
$4.4[B];
Metropolitan Human Services District expenditures: Percentage: 101[C];
Jefferson Parish Human Services Authority expenditures: Dollars in
millions: $7.5[D];
Jefferson Parish Human Services Authority expenditures: Percentage:
100.
Source: GAO analysis of Louisiana Department of Health and Hospitals
data.
Note: The funds in this table were expended either through contracts to
other organizations and providers or through direct services and
related expenses.
[A] Behavioral health is a term often used to refer to mental health
and substance abuse services.
[B] The total does not equal Metropolitan Human Services District's
expenditures of $4.3 million because of rounding.
[C] The total does not equal 100 percent because of rounding.
[D] As of March 3, 2009, Jefferson Parish Human Services Authority had
not expended about $88,000 of its total distribution of $7.6 million.
[End of table]
MHSD officials told us they used the SSBG supplemental funds to help
maintain staff and relocate them to community-based mental health
centers, where clients could be assessed and treated for mental health
and addiction problems. In addition, MHSD placed an addiction counselor
in a school-based health center to provide early intervention and
treatment for substance abuse. MHSD officials also reported that they
used funds to support crisis and addiction counseling for adults and
children in churches, grief counseling for children in elementary
schools, a summer camp that included mental health counseling, and
community outreach services.
JPHSA officials told us they used SSBG supplemental funds to provide
services such as assertive community treatment,[Footnote 39] crisis
intervention teams,[Footnote 40] mobile crisis services,[Footnote 41]
suicide prevention services, group and individual therapy, and
psychiatric evaluation. For example, JPHSA expanded its assertive
community treatment program, in which services are provided at home or
in community-based locations and include help with medication
administration and monitoring. JPHSA officials reported that this
program focused on patients who had a history of noncompliance with
mental health treatment and were generally considered to be the persons
most in need of mental health services. JPHSA also used the funds to
support a program of community-based services for patients who were no
longer in need of inpatient services or who were in crisis but not in
need of an inpatient psychiatric hospital stay. Patients were given 24-
hour care and supervision and attended group and individual counseling
designed to provide crisis resolution skills and coping strategies;
they were also linked to community-based resources such as community
mental health clinics and supportive or independent housing. This
program also served to alleviate the burden on inpatient psychiatric
hospitals.
About Two-Thirds of the PCASG Fund Recipients Employed a Health Care
Provider Who Received a Professional Workforce Supply Grant Incentive
Payment, and More Incentives Were Used for Retention Than for Hiring:
As of August 2008, 17 of the 25 PCASG fund recipients had retained or
hired a health care provider who had received a Professional Workforce
Supply Grant incentive payment to continue or begin working in the
greater New Orleans area.[Footnote 42] Among the health care providers
working for PCASG fund recipients, 69 received incentives that totaled
$4.5 million. (See table 5.) The number of those health care providers
who were employed by individual PCASG fund recipients ranged from 1 or
2 at 7 recipient organizations to 10 at 2 recipient organizations.
These one-time, lump sum incentive payments, which could be used for
purposes such as student loan repayment or relocation expenses, ranged
from $10,000 to $110,000 each; the largest percentages of incentive
payments and of funds went to primary care providers.[Footnote 43] In a
2008 survey conducted by LDHH, 88 percent of all incentive recipients
reported that the availability of an incentive payment affected their
decision to remain or practice in the greater New Orleans area.
[Footnote 44]
Table 5: Health Care Providers Who Received Professional Workforce
Supply Grant Incentive Payments and Were Employed by Primary Care
Access and Stabilization Grant (PCASG) Fund Recipients, by Provider
Type, through August 2008:
Provider type[A]: Primary care;
Health care providers who received a Professional Workforce Supply
Grant incentive payment and were employed by a PCASG fund recipient:
Number of health care providers who received an incentive: 29;
Health care providers who received a Professional Workforce Supply
Grant incentive payment and were employed by a PCASG fund recipient:
Percentage of health care providers who received an incentive: 42;
Professional Workforce Supply Grant incentive payments to health care
providers employed by a PCASG fund recipient: Dollars (in thousands):
$2,806;
Professional Workforce Supply Grant incentive payments to health care
providers employed by a PCASG fund recipient: Percentage of funding:
63.
Provider type[A]: Mental health;
Health care providers who received a Professional Workforce Supply
Grant incentive payment and were employed by a PCASG fund recipient:
Number of health care providers who received an incentive: 16;
Health care providers who received a Professional Workforce Supply
Grant incentive payment and were employed by a PCASG fund recipient:
Percentage of health care providers who received an incentive: 23;
Professional Workforce Supply Grant incentive payments to health care
providers employed by a PCASG fund recipient: Dollars (in thousands):
$1,030;
Professional Workforce Supply Grant incentive payments to health care
providers employed by a PCASG fund recipient: Percentage of funding:
23.
Provider type[A]: Registered nurses;
Health care providers who received a Professional Workforce Supply
Grant incentive payment and were employed by a PCASG fund recipient:
Number of health care providers who received an incentive: 14;
Health care providers who received a Professional Workforce Supply
Grant incentive payment and were employed by a PCASG fund recipient:
Percentage of health care providers who received an incentive: 20;
Professional Workforce Supply Grant incentive payments to health care
providers employed by a PCASG fund recipient: Dollars (in thousands):
$225;
Professional Workforce Supply Grant incentive payments to health care
providers employed by a PCASG fund recipient: Percentage of funding: 5.
Provider type[A]: Allied health[B];
Health care providers who received a Professional Workforce Supply
Grant incentive payment and were employed by a PCASG fund recipient:
Number of health care providers who received an incentive: 7;
Health care providers who received a Professional Workforce Supply
Grant incentive payment and were employed by a PCASG fund recipient:
Percentage of health care providers who received an incentive: 10;
Professional Workforce Supply Grant incentive payments to health care
providers employed by a PCASG fund recipient: Dollars (in thousands):
$85;
Professional Workforce Supply Grant incentive payments to health care
providers employed by a PCASG fund recipient: Percentage of funding: 2.
Provider type[A]: Dental health;
Health care providers who received a Professional Workforce Supply
Grant incentive payment and were employed by a PCASG fund recipient:
Number of health care providers who received an incentive: 3;
Health care providers who received a Professional Workforce Supply
Grant incentive payment and were employed by a PCASG fund recipient:
Percentage of health care providers who received an incentive: 4;
Professional Workforce Supply Grant incentive payments to health care
providers employed by a PCASG fund recipient: Dollars (in thousands):
$330;
Professional Workforce Supply Grant incentive payments to health care
providers employed by a PCASG fund recipient: Percentage of funding: 7.
Provider type[A]: Total;
Health care providers who received a Professional Workforce Supply
Grant incentive payment and were employed by a PCASG fund recipient:
Number of health care providers who received an incentive: 69;
Health care providers who received a Professional Workforce Supply
Grant incentive payment and were employed by a PCASG fund recipient:
Percentage of health care providers who received an incentive: 99[C];
Professional Workforce Supply Grant incentive payments to health care
providers employed by a PCASG fund recipient: Dollars (in thousands):
$4,476;
Professional Workforce Supply Grant incentive payments to health care
providers employed by a PCASG fund recipient: Percentage of funding:
100.
Source: GAO analysis of data provided by Louisiana Department of Health
and Hospitals.
Note: Additional health care providers who received incentive payments
may be employed by the PCASG fund recipients, but not at sites eligible
to use PCASG funds.
[A] The Professional Workforce Supply Grant also provides incentive
payments to faculty and specialists; however, none were employed by a
PCASG fund recipient.
[B] Allied health includes therapists, such as registered respiratory
therapists, occupational therapists, and physical therapists, and
specialists, such as clinical laboratory personnel, licensed addiction
counselors, and licensed practical nurses.
[C] The total does not equal 100 percent because of rounding.
[End of table]
Three-quarters of recipients of incentive payments were existing
employees who were retained, while one-quarter were newly hired. This
pattern is consistent with the incentive payments that were made
overall, regardless of employing organization. In addition, no PCASG
fund recipient hired more than two new staff who had received an
incentive payment. In discussing these payments, a state official
commented that retaining an existing employee is generally easier than
hiring a new one.
One PCASG Fund Recipient Provided Counseling Services through the CCP:
One PCASG fund recipient provided counseling services with CCP funds.
In 2005, immediately following Hurricane Katrina, the Louisiana Office
of Mental Health contracted with Catholic Charities Archdiocese of New
Orleans to be the sole CCP service provider in the four area parishes.
This recipient expended $7.9 million of the $29 million in CCP funds
awarded to Louisiana. In addition to providing counseling services,
Catholic Charities' counselors provided information about available
services such as primary care; mental health services; substance abuse
treatment; and food, clothing, and housing assistance. Catholic
Charities terminated its CCP role in May 2007, and the Louisiana Office
of Mental Health took over its role.[Footnote 45]
PCASG Fund Recipients Face Multiple Challenges and Have Various Plans
for Sustainability:
PCASG fund recipients face significant challenges in hiring and
retaining staff, as well as in referring patients outside of their
organizations, and these challenges have grown since Hurricane Katrina.
Recipients are taking actions to address the challenge of
sustainability, but it is too early to know whether they will be
successful.
PCASG Fund Recipients Face Significant Staffing and Referral
Challenges, and These Challenges Have Grown Since Hurricane Katrina:
Although most of the 23 PCASG fund recipients that responded to our
survey hired or retained staff with grant funds, most have continued to
face significant challenges in hiring and retaining staff. Hiring has
been especially challenging. For example, 11 of the 23 recipients
reported the hiring of health care providers to be a great challenge,
and 9 reported it was a moderate challenge. (For detailed information
on recipients' responses to the questions in our Web-based survey
regarding challenges, see figure 3.) Among those that reported hiring
providers was a great or moderate challenge, over three-quarters
responded that this challenge had grown since Hurricane
Katrina.[Footnote 46] In discussing challenges, officials from one
recipient organization told us that after Hurricane Katrina they had
greater difficulty hiring licensed nurses than before the hurricane.
They also told us that most of the nurses who were available to be
hired were recruited by hospitals, where the pay was higher. Moreover,
officials we interviewed from several recipient organizations said that
the problems with housing, schools, and overall community
infrastructure that developed after Hurricane Katrina made it difficult
to attract health care providers and other staff. An additional
indication of limited availability of primary care providers in the
area is HRSA's designation of all of Orleans, Plaquemines, and St.
Bernard parishes and much of Jefferson Parish as HPSAs for primary
care.[Footnote 47] While some portions of the greater New Orleans area
had this HPSA designation before Hurricane Katrina, additional portions
of the area received that designation after the hurricane.
Figure 3: Ratings by Primary Care Access and Stabilization Grant
(PCASG) Fund Recipients of Challenges to Providing Primary Care
Services, and Comparison with Period Prior to Hurricane Katrina:
[Refer to PDF for image: two illustrated tables]
Ratings of Current Challenges:
To what extent do the items listed below present challenges for your
organization in providing primary health care services to the greater
New Orleans area?
Hiring of health care providers:
Great extent: 11;
Moderate extent: 9;
Minor extent or not at all: 3;
No basis to judge/not applicable: 0.
Hiring of staff other than health care providers:
Great extent: 9;
Moderate extent: 8;
Minor extent or not at all: 6;
No basis to judge/not applicable: 0.
Retention of health care providers:
Great extent: 7;
Moderate extent: 9;
Minor extent or not at all: 7;
No basis to judge/not applicable: 0.
Retention of staff other than health care providers:
Great extent: 5;
Moderate extent: 9;
Minor extent or not at all: 9;
No basis to judge/not applicable: 0.
Availability of mental health providers willing to accept referrals:
Great extent: 9;
Moderate extent: 5;
Minor extent or not at all: 8;
No basis to judge/not applicable: 1.
Availability of dentists willing to accept dental care:
Great extent: 6;
Moderate extent: 4;
Minor extent or not at all: 6;
No basis to judge/not applicable: 7.
Availability of health care providers willing to accept specialty care
referrals:
Great extent: 9;
Moderate extent: 4;
Minor extent or not at all: 7;
No basis to judge/not applicable: 3.
For those who rated the challenges to be great or moderate, we further
analyzed their answers to the question below.
Current challenges compared to those prior to Katrina:
How do the current challenges your organization faces compare to those
it faced prior to Hurricane Katrina?
Hiring of health care providers:
Greater now than before Katrina: 13;
Equal to or less now than before Katrina: 3;
No basis to judge/not applicable: 4.
Hiring of staff other than health care providers:
Greater now than before Katrina: 11;
Equal to or less now than before Katrina: 4;
No basis to judge/not applicable: 2.
Retention of health care providers:
Greater now than before Katrina: 10;
Equal to or less now than before Katrina: 3;
No basis to judge/not applicable: 3.
Retention of staff other than health care providers:
Greater now than before Katrina: 9;
Equal to or less now than before Katrina: 4;
No basis to judge/not applicable: 1.
Availability of mental health providers willing to accept referrals:
Greater now than before Katrina: 10;
Equal to or less now than before Katrina: 1;
No basis to judge/not applicable: 3.
Availability of dentists willing to accept dental care referrals:
Greater now than before Katrina: 6;
Equal to or less now than before Katrina: 2;
No basis to judge/not applicable: 2.
Availability of health care providers willing to accept specialty care
referrals:
Greater now than before Katrina: 9;
Equal to or less now than before Katrina: 1;
No basis to judge/not applicable: 3.
Source: GAO analysis of responses by PCASG fund recipients to GAO’s Web-
based survey.
Note: Twenty-three of the 25 PCASG fund recipients responded to the
survey.
[End of figure]
Retention of staff has also been a challenge for the PCASG fund
recipients. (See figure 3.) For example, 16 of the 23 recipients
reported that retaining health care providers was a great or moderate
challenge. Among those that reported retaining health care providers
was a great or moderate challenge, about three-quarters also reported
that this challenge had grown since Hurricane Katrina. Retaining other
staff has also been a challenge, with 14 of the 23 recipients reporting
it to be a great or moderate challenge. About two-thirds of those
reporting that retaining other staff was a moderate or great challenge
also said this challenge had grown since Hurricane Katrina.
The PCASG fund recipients that primarily provide mental health services
in particular faced challenges both in hiring providers and in
retaining providers.[Footnote 48] Six of the seven that responded to
our survey reported that both hiring and retaining providers were
either a great or moderate challenge. Six recipients reported that
hiring was a great challenge, and five of these reported that the
challenge was greater than before Hurricane Katrina. Three recipients
reported that retention was a great challenge, and two of these also
reported that the challenge had grown since Hurricane Katrina. An
indication of more limited availability of mental health care providers
is HRSA's designation of the four parishes of the greater New Orleans
area as HPSAs for mental health in late 2005 and early 2006; before
Hurricane Katrina, none of the parishes had this designation for mental
health.[Footnote 49] Officials we interviewed from one recipient with
multiple sites told us that while the Greater New Orleans Health
Service Corps, which was funded through the Professional Workforce
Supply Grant, had been helpful for recruiting and retaining physicians,
it had not helped fill the need for social workers. Furthermore,
officials we interviewed from two recipients with multiple sites told
us that some staff had experienced depression and trauma themselves and
found it difficult to work in mental health settings.
Beyond challenges in hiring and retaining their own providers and other
staff, PCASG fund recipients that responded to our survey reported
significant challenges in referring their patients to other
organizations for mental health, dental, and specialty care services.
(See figure 3.) Specifically, 14 of the 23 recipients reported that the
availability of mental health providers willing to accept referrals was
a great or moderate challenge, and over two-thirds of those reporting
that level of challenge responded that this challenge had grown since
Hurricane Katrina. In addition, 10 of the 16 recipients that indicated
that the question on dental service referrals was applicable to them
reported that the availability of dentists willing to accept referrals
was a great or moderate challenge, and about two-thirds of those
reporting that level of challenge also reported that this challenge was
greater than before Hurricane Katrina. An additional indication of
limited availability of dental care is that HRSA has designated all of
Orleans, St. Bernard, and Plaquemines parishes and part of Jefferson
Parish as HPSAs for dental care; before Katrina, only part of Orleans
Parish and part of Jefferson Parish had this designation.[Footnote 50]
Finally, 13 of the 20 recipients that indicated that the question on
specialty care referrals was applicable to them reported that the
availability of providers willing to accept referrals for specialty
care was a great or moderate challenge,[Footnote 51] and two-thirds of
those reported that this challenge had grown since Hurricane Katrina.
PCASG Fund Recipients Are Taking Actions to Address the Challenge of
Sustainability, but It Is Too Early to Know Whether They Will Be
Successful:
An additional challenge that the PCASG fund recipients face is to be
sustainable after PCASG funds are no longer available. All 23
recipients that responded to our survey reported that they had taken or
planned to take at least one type of action to increase their ability
to be sustainable--that is, to be able to serve patients regardless of
their ability to pay after PCASG funds are no longer available. For
example, all responding recipients reported that they had taken action-
-such as screening patients for eligibility--to facilitate their
ability to receive reimbursement for services they provided to Medicaid
or LaCHIP beneficiaries. Furthermore, 16 recipients reported that they
were billing private insurance, with an additional 5 recipients
reporting they planned to do so. However, obtaining reimbursement for
all patients who are insured may not be sufficient to ensure a
recipient's sustainability, because at about half of the PCASG fund
recipients, over 50 percent of the patients are uninsured.
Many PCASG fund recipients reported that they intended to use Health
Center Program funding or FQHC Look-Alike designation--which allows for
enhanced Medicare and Medicaid payment rates--as one of their
sustainability strategies. Four recipients were participating in the
Health Center Program at the time they received the initial
disbursement of PCASG funds. One of these recipients had received a
Health Center New Access Point grant to open an additional site after
Hurricane Katrina and had also received an Expanded Medical Capacity
grant to increase service capacity, which it used in part to hire
additional staff and buy equipment. Another of these recipients
received a New Access Point grant to open an additional site after
receiving PCASG funds. Beyond these four recipients, one additional
recipient received an FQHC Look-Alike designation in July 2008 and a
New Access Point grant in March 2009. Of the remaining 18 recipients
that responded to our survey, 6 said they planned to apply for both a
Health Center Program grant and an FQHC Look-Alike designation. In
addition, 1 planned to apply for a grant only and another planned to
apply for an FQHC Look-Alike designation only. Although many recipients
indicated that they intended to use Health Center Program funding as a
sustainability strategy, they may not all be successful in obtaining a
grant. For example, in fiscal year 2008 only about 16 percent of all
applications for New Access Point grants resulted in grant awards.
[Footnote 52]
About three-quarters of PCASG fund recipients reported that as one of
their sustainability strategies they had applied or planned to apply
for additional federal funding, such as Ryan White HIV/AIDS Program
grants,[Footnote 53] or for state funding. In addition, a few reported
that they had applied or planned to apply for private grants, such as
from foundations.
Although PCASG fund recipients have completed or planned actions to
increase their ability to be sustainable, it is too early to know
whether their various sustainability strategies will be successful. One
factor that may affect the degree of challenge in achieving
sustainability is whether a recipient is part of a larger institution,
such as a university or government body, that could potentially provide
additional funds after PCASG funds are no longer available. Similarly,
sustainability may be a less difficult challenge for organizations that
are already grantees of HRSA's Health Center Program.
Agency Comments:
HHS reviewed a draft of this report and provided technical comments,
which we incorporated as appropriate.
As agreed with your offices, unless you publicly announce the contents
of this report earlier, we plan no further distribution until 30 days
from the report date. At that time, we will send copies of this report
to the Secretary of Health and Human Services and other interested
parties. In addition, the report will be available at no charge on the
GAO Web site at [hyperlink, http://www.gao.gov].
If you or your staffs have any questions about this report, please
contact me at (202) 512-7114 or bascettac@gao.gov. Contact points for
our Offices of Congressional Relations and Public Affairs may be found
on the last page of this report. GAO staff who made major contributions
to this report are listed in appendix III.
Signed by:
Cynthia A. Bascetta:
Director, Health Care:
[End of section]
Appendix I: Scope and Methodology:
We focused our review on the 25 outpatient provider organizations that
in September 2007 received funding through the Primary Care Access and
Stabilization Grant (PCASG), which the Department of Health and Human
Services (HHS) awarded to the Louisiana Department of Health and
Hospitals (LDHH). The PCASG funds were targeted to the greater New
Orleans area--specifically, Jefferson, Orleans, Plaquemines, and St.
Bernard parishes--because of the impact Hurricane Katrina had on this
area. In this report we examine (1) how PCASG fund recipients used the
PCASG funds to support the provision of primary care services in the
greater New Orleans area, (2) how PCASG fund recipients used and
benefited from other federal hurricane relief funds that support the
restoration of primary care services in the greater New Orleans area,
and (3) challenges the PCASG fund recipients continued to face in
providing primary care services, and recipients' plans for sustaining
services after PCASG funds are no longer available.
In conducting our work, we reviewed relevant literature. We also
interviewed officials at various agencies within HHS, including the
Administration for Children and Families, Centers for Medicare &
Medicaid Services (CMS), Health Resources and Services Administration
(HRSA), and Substance Abuse and Mental Health Services Administration.
To determine how the PCASG fund recipients used PCASG funds to support
the provision of primary care services in the greater New Orleans
area,[Footnote 54] we conducted site visits and developed and
implemented a Web-based survey. We also reviewed the recipients' grant
applications and interviewed officials at the LDHH and Louisiana Public
Health Institute (LPHI) about how the recipients used PCASG funds. LPHI
administers the PCASG program and distributes the grant funds as the
local partner of LDHH.
We conducted site visits at 8 of the 25 PCASG fund recipients during
April 2008. During these visits we collected documents and interviewed
PCASG fund recipient, state, and local officials. To identify the
locations for our site visits, we chose a selective sample of the
recipients to include at least 1 from each of the area's four parishes.
We also selected recipients so that our sample would include some that
offered mental health care services and some that offered dental care
services, and we included 2 recipients that were grant recipients of
HRSA's Health Center Program.
We developed a Web-based survey that focused on how PCASG fund
recipients used PCASG funds, the challenges they continued to face, and
their plans for sustainability. To develop our survey questions, we
analyzed our interviews with officials from PCASG fund recipients, CMS,
and state and local agencies; reviewed the recipients' applications for
funding; and reviewed the PCASG Notice of Award. In addition, before we
disseminated the survey to the 25 recipients, the content of the survey
questions was peer-reviewed by LPHI because of its expertise on the
grant program. We received responses from 23 of the 25 recipients, a
response rate of 92 percent. To assess the reliability of the survey
data, we performed quality checks, such as reviewing survey data for
inconsistencies and completeness and, when necessary, followed up with
survey respondents via the telephone to resolve any inconsistencies and
obtain missing information. Based on these efforts, we determined that
the survey data were sufficiently reliable for the purposes of this
report.
To answer our question on how the PCASG fund recipients used and
benefited from other federal funds for hurricane relief, we reviewed
and analyzed data collected by LDHH on expenditures related to the
supplemental Social Services Block Grant (SSBG). Where possible, we
used documents from and interviews with state and PCASG fund recipient
officials to identify SSBG supplemental funds expended at PCASG sites.
In addition, we reviewed and analyzed data gathered by LDHH related to
the incentive payments made under the Professional Workforce Supply
Grant and expenditures under the Crisis Counseling Assistance and
Training Program (CCP). For the incentive payments made using the
Professional Workforce Supply Grant, LDHH provided us with information
about health care providers working at PCASG sites. They used the
employment address, rather than recipient name, to identify which
providers to include. They provided data about the amount of payment,
payment type (retention or hiring), and provider type (for example,
internist or nurse). For the CCP, we obtained data from LDHH on program
expenditures at PCASG sites. We also interviewed officials from LDHH
and PCASG fund recipients about the implementation of these programs in
the greater New Orleans area. To assess the reliability of the data we
received from LDHH related to the SSBG, Professional Workforce Supply
Grant, and CCP, we performed checks of internal consistency and
verified information with state and local officials where possible.
Based on these efforts, we determined that the data were sufficiently
reliable for the purposes of this report.
To answer our questions on challenges PCASG fund recipients continued
to face in providing primary care services and how PCASG fund
recipients plan to sustain primary care services after funds are no
longer available, we used information collected from our Web-based
survey. We also analyzed interviews we conducted with 10 recipients,
including the 8 we visited, and from federal, state, and local
agencies. In addition, to determine how recipients planned to sustain
primary care services, we reviewed sustainability plans that the
recipients included in their applications for PCASG funding. We also
analyzed information provided by HRSA on Health Center Program grants
awarded to PCASG fund recipients and on overall program grants awarded
in fiscal years 2007 and 2008.
To provide additional information on the PCASG fund recipients, we used
data collected by LPHI about the recipients. We analyzed data that LPHI
provided to us on each PCASG fund recipient for the period September
21, 2007, through March 20, 2008, regarding (1) patients and
encounters,[Footnote 55] and (2) types of services that recipients
offered.[Footnote 56] We obtained these data for this period because at
the time of our request, this was the only period for which LPHI had
completed its data accuracy and reliability checks on the patient and
encounter data. We requested that LPHI summarize for us at the
recipient level both the number of patients and the number of
encounters, by age and insurance status.[Footnote 57]
To assess the reliability of data we received from LPHI on patient and
encounter data and on types of services offered, we did the following:
(1) reviewed relevant documentation, (2) discussed with knowledgeable
agency officials the data and the processes they used to establish the
accuracy and reliability of the data provided, and (3) where possible,
compared data to published sources. Based on these activities, we
determined that these data were sufficiently reliable for the purposes
of our report.
We conducted our work from February 2008 through June 2009 in
accordance with all sections of GAO's Quality Assurance Framework that
are relevant to our objectives. The framework requires that we plan and
perform the engagement to obtain sufficient and appropriate evidence to
meet our stated objectives and to discuss any limitations in our work.
We believe that the information and data obtained, and the analysis
conducted, provide a reasonable basis for any findings and conclusions
in this product.
[End of section]
Appendix II: Primary Care Access and Stabilization Grant Fund
Recipients: Characteristics, Patients, and Services:
In July 2007, HHS awarded the $100 million PCASG to LDHH,[Footnote 58]
which in turn provided funds to 25 outpatient provider organizations in
the greater New Orleans area in September 2007.[Footnote 59] CMS is
responsible for administering the program at the federal level. LPHI is
LDHH's local partner for administering the grant program.
The 25 organizations that are PCASG fund recipients vary in size and in
the geographical area they serve. (See table 6.) Furthermore, some
recipients are affiliated with an institution such as a university or
state or local government, and some receive funding from the Health
Center Program of HHS's HRSA.[Footnote 60]
Table 6: Selected Characteristics of Primary Care Access and
Stabilization Grant (PCASG) Fund Recipients, September 21, 2007,
through March 20, 2008:
Recipient: Administrators of Tulane Educational Fund[C];
Parish where services provided: Orleans;
Number of sites[B]: 5;
Type of primary health care services offered[A]: Medical: [Check];
Type of primary health care services offered[A]: Mental: [Check];
Type of primary health care services offered[A]: Dental: [Empty].
Recipient: Catholic Charities Archdiocese of New Orleans;
Parish where services provided: Orleans and Jefferson;
Number of sites[B]: 3;
Type of primary health care services offered[A]: Medical: [Empty];
Type of primary health care services offered[A]: Mental: [Check];
Type of primary health care services offered[A]: Dental: [Empty].
Recipient: Children's Hospital Medical Practice Corporation;
Parish where services provided: Orleans and Jefferson;
Number of sites[B]: 11;
Type of primary health care services offered[A]: Medical: [Check];
Type of primary health care services offered[A]: Mental: [Check];
Type of primary health care services offered[A]: Dental: [Check].
Recipient: City of New Orleans Health Department;
Parish where services provided: Orleans;
Number of sites[B]: 4[D];
Type of primary health care services offered[A]: Medical: [Check];
Type of primary health care services offered[A]: Mental: [Check];
Type of primary health care services offered[A]: Dental: [Check].
Recipient: Common Ground Health Clinic;
Parish where services provided: Orleans;
Number of sites[B]: 2;
Type of primary health care services offered[A]: Medical: [Check];
Type of primary health care services offered[A]: Mental: [Check];
Type of primary health care services offered[A]: Dental: [Check].
Recipient: Covenant House New Orleans;
Parish where services provided: Orleans;
Number of sites[B]: 1;
Type of primary health care services offered[A]: Medical: [Empty];
Type of primary health care services offered[A]: Mental: [Check];
Type of primary health care services offered[A]: Dental: [Empty].
Recipient: Daughters of Charity Services of New Orleans;
Parish where services provided: Orleans and Jefferson;
Number of sites[B]: 5;
Type of primary health care services offered[A]: Medical: [Check];
Type of primary health care services offered[A]: Mental: [Check];
Type of primary health care services offered[A]: Dental: [Empty].
Recipient: EXCELth, Inc.;
Parish where services provided: Orleans;
Number of sites[B]: 2;
Type of primary health care services offered[A]: Medical: [Check];
Type of primary health care services offered[A]: Mental: [Check];
Type of primary health care services offered[A]: Dental: [Empty].
Recipient: Jefferson Community Health Care Centers, Inc.;
Parish where services provided: Jefferson;
Number of sites[B]: 3;
Type of primary health care services offered[A]: Medical: [Check];
Type of primary health care services offered[A]: Mental: [Check];
Type of primary health care services offered[A]: Dental: [Empty].
Recipient: Jefferson Parish Human Services Authority;
Parish where services provided: Jefferson;
Number of sites[B]: 4;
Type of primary health care services offered[A]: Medical: [Empty];
Type of primary health care services offered[A]: Mental: [Check];
Type of primary health care services offered[A]: Dental: [Empty].
Recipient: Leading Edge Services International (also known as Family
Health Center);
Parish where services provided: Jefferson;
Number of sites[B]: 1;
Type of primary health care services offered[A]: Medical: [Check];
Type of primary health care services offered[A]: Mental: [Check];
Type of primary health care services offered[A]: Dental: [Empty].
Recipient: LSU Healthcare Network Behavioral Science Center;
Parish where services provided: Orleans;
Number of sites[B]: 1;
Type of primary health care services offered[A]: Medical: [Empty];
Type of primary health care services offered[A]: Mental: [Check];
Type of primary health care services offered[A]: Dental: [Empty].
Recipient: LSU Health Sciences Center New Orleans (School Based Health
Centers);
Parish where services provided: Orleans;
Number of sites[B]: 2;
Type of primary health care services offered[A]: Medical: [Check];
Type of primary health care services offered[A]: Mental: [Check];
Type of primary health care services offered[A]: Dental: [Empty].
Recipient: Lower 9th Ward Health Clinic;
Parish where services provided: Orleans;
Number of sites[B]: 1;
Type of primary health care services offered[A]: Medical: [Check];
Type of primary health care services offered[A]: Mental: [Empty];
Type of primary health care services offered[A]: Dental: [Empty].
Recipient: Medical Center of Louisiana at New Orleans;
Parish where services provided: Orleans;
Number of sites[B]: 9;
Type of primary health care services offered[A]: Medical: [Check];
Type of primary health care services offered[A]: Mental: [Check];
Type of primary health care services offered[A]: Dental: [Check].
Recipient: Metropolitan Human Services District[E];
Parish where services provided: Orleans, Plaquemines, and St. Bernard;
Number of sites[B]: 7;
Type of primary health care services offered[A]: Medical: [Check];
Type of primary health care services offered[A]: Mental: [Check];
Type of primary health care services offered[A]: Dental: [Empty].
Recipient: New Orleans Adolescent Hospital and Community Services;
Parish where services provided: Orleans;
Number of sites[B]: 4;
Type of primary health care services offered[A]: Medical: [Empty];
Type of primary health care services offered[A]: Mental: [Check];
Type of primary health care services offered[A]: Dental: [Empty].
Recipient: New Orleans Musicians' Assistance Foundation;
Parish where services provided: Orleans;
Number of sites[B]: 2;
Type of primary health care services offered[A]: Medical: [Check];
Type of primary health care services offered[A]: Mental: [Check];
Type of primary health care services offered[A]: Dental: [Empty].
Recipient: NO/AIDS Task Force;
Parish where services provided: Orleans;
Number of sites[B]: 1;
Type of primary health care services offered[A]: Medical: [Check];
Type of primary health care services offered[A]: Mental: [Check];
Type of primary health care services offered[A]: Dental: [Empty].
Recipient: Odyssey House Louisiana, Inc.[F];
Parish where services provided: Orleans;
Number of sites[B]: 2;
Type of primary health care services offered[A]: Medical: [Check];
Type of primary health care services offered[A]: Mental: [Check];
Type of primary health care services offered[A]: Dental: [Empty].
Recipient: Plaquemines Medical Center;
Parish where services provided: Plaquemines;
Number of sites[B]: 1;
Type of primary health care services offered[A]: Medical: [Check];
Type of primary health care services offered[A]: Mental: [Empty];
Type of primary health care services offered[A]: Dental: [Empty].
Recipient: Sisters of Mercy Ministries (also known as Mercy Family
Center);
Parish where services provided: Jefferson;
Number of sites[B]: 1;
Type of primary health care services offered[A]: Medical: [Empty];
Type of primary health care services offered[A]: Mental: [Check];
Type of primary health care services offered[A]: Dental: [Empty].
Recipient: St. Bernard Health Center, Inc.;
Parish where services provided: St. Bernard;
Number of sites[B]: 1;
Type of primary health care services offered[A]: Medical: [Check];
Type of primary health care services offered[A]: Mental: [Empty];
Type of primary health care services offered[A]: Dental: [Empty].
Recipient: St. Charles Community Health Center - Kenner;
Parish where services provided: Jefferson;
Number of sites[B]: 1;
Type of primary health care services offered[A]: Medical: [Check];
Type of primary health care services offered[A]: Mental: [Check];
Type of primary health care services offered[A]: Dental: [Empty].
Recipient: St. Thomas Community Health Center;
Parish where services provided: Orleans;
Number of sites[B]: 1;
Type of primary health care services offered[A]: Medical: [Check];
Type of primary health care services offered[A]: Mental: [Check];
Type of primary health care services offered[A]: Dental: [Empty].
Source: GAO analysis of the Louisiana Public Health Institute's (LPHI)
summary of data reported by PCASG fund recipients.
Notes: The Department of Health and Human Services awarded the PCASG to
the Louisiana Department of Health and Hospitals in July 2007 to
restore and expand access to primary care services, including mental
health care services and dental care services, in the greater New
Orleans area; 25 outpatient provider organizations that applied and met
the requirements established by CMS were awarded PCASG funding.
September 21, 2007, through March 20, 2008, was the first period for
which PCASG fund recipients reported data on their activities to LPHI.
[A] The primary health care services offered represent those that were
offered at sites eligible to use PCASG funds; health care services that
were provided through referral are not included in the table.
[B] The number of sites is the number eligible to use PCASG funds and
operating during the period September 21, 2007, through March 20, 2008.
Some of the PCASG fund recipients had other sites that were not
eligible to use PCASG funds.
[C] The Administrators of Tulane Educational Fund is part of Tulane
University.
[D] Although the City of New Orleans Health Department operated 4 sites
during the period September 21, 2007, through March 20, 2008, the
department provided data for only 2 of these sites.
[E] The Metropolitan Human Services District primarily provides mental
health care services. At the patient's request, it also provides
pregnancy testing.
[F] Odyssey House Louisiana, Inc. primarily provides mental health care
services. However, it hosts with other organizations a clinic that
offers medical care services.
[End of table]
For the period September 21, 2007, through March 20, 2008,[Footnote 61]
the PCASG fund recipients provided primary care services to a
population that was largely uninsured or enrolled in Medicaid.[Footnote
62] The recipients reported to LPHI that they used PCASG funds to
support services provided to about 82,400 patients. The recipients also
used other funds, such as other federal grants or Medicaid
reimbursement, to support these services. Almost three-quarters of the
recipients' patients were either uninsured or enrolled in Medicaid or
the Louisiana Children's Health Insurance Program (LaCHIP).[Footnote
63] (See figure 4.) At more than half of the PCASG fund recipients, at
least 50 percent of their patient population was uninsured, and for
most of these recipients the uninsured patient population was greater
than 70 percent. Overall, 18 percent of patients served by the
recipients were privately insured, although three recipients served a
privately insured population of over 40 percent.
Figure 4: Primary Care Access and Stabilization Grant (PCASG) Fund
Recipients' Patient Population, by Health Insurance Status, September
21, 2007, through March 20, 2008:
[Refer to PDF for image: pie-chart]
Uninsured (35,650): 43%;
Medicaid or LaCHIP (23,572): 29%;
Private (14,896): 18%;
Medicare (3,916): 5%;
Other[A] (2,211): 3%;
Missing and unknown (2,155): 3%.
Source: GAO analysis of Louisiana Public Health Institute’s (LPHI)
summary of data reported by PCASG fund recipients.
Notes: The patient population equals 82,401. The percentages do not
total to 100 percent due to rounding. These data were collected by LPHI
from the 25 PCASG fund recipients.
[A] "Other" includes patients who were in different insurance
categories for two or more encounters, such as patients who were
uninsured at the time of the first encounter and were covered by
Medicaid at the time of the second encounter.
[End of figure]
The 25 PCASG fund recipients varied in the mix of primary care services
they offered. During the reporting period, 19 of the recipients
reported to LPHI that they offered medical care services, either solely
or in combination with mental health care services.[Footnote 64] Of
these 19 recipients, 4 also offered dental care services. A total of 22
recipients offered mental health care services, such as counseling,
psychiatry, and services related to substance abuse. The recipients
also offered certain specialty care services and ancillary services.
Eleven recipients either directly offered the specialty care services
of podiatry, optometry, and tuberculosis therapy[Footnote 65] or
provided referrals to organizations that provided these services.
Almost all of the recipients offered ancillary services in addition to
providing primary care services. For example, translation and
interpretation, health education, and outreach services were each
offered at over half of the recipients.
The PCASG fund recipients reported to LPHI that they provided nearly
194,000 health care encounters during the period September 21, 2007,
through March 20, 2008.[Footnote 66] Sixty percent of encounters were
for medical or dental care,[Footnote 67] 38 percent for mental health
care, and 1 percent for specialty care. (See figure 5.) For medical and
dental care encounters and for mental health care encounters, adults
represented about two-thirds of the encounters and children about one-
third. Almost half of the medical and dental care encounters were with
patients who were uninsured, and more than one-third of the mental
health encounters were provided to uninsured patients. About one-third
of both medical and dental care encounters and mental health care
encounters were with Medicaid or LaCHIP beneficiaries.
Figure 5: Encounters at Primary Care Access and Stabilization Grant
(PCASG) Fund Recipients, by Service Type, September 21, 2007, through
March 20, 2008:
[Refer to PDF for image: series of related pie-charts]
Total encounters[A] (N=193,745):
* Medical and dental care[B] (N = 116,820 - 60%):
By age:
0-4: 17,654 (15%);
5-17: 22,391 (19%);
18-64: 69,558 (60%);
65+: 7,168 (6%);
Missing: 49 (<1%).
By insurance status:
Medicaid or LaCHIP: 34,818 (30%);
Medicare: 6,944 (6%);
Private: 20,996 (18%);
Uninsured: 53,277 (46%);
Other[C]: 28 (<1%);
Missing: 757 (<1%).
* Mental health care (N = 73,412 - 38%):
By age:
0-4: 240 (<1%);
5-17: 23,194 (32%);
18-64: 47,977 (65%);
65+: 1,920 (3%);
Missing: 81 (<1%).
By insurance status:
Medicaid or LaCHIP: 26,156 (36%);
Medicare: 5,050 (7%);
Private: 6,110 (8%);
Uninsured: 27,660 (38%);
Other[C]: 1,250 (2%);
Missing: 7,186 (10%).
* Specialty care (N = 2,273 - 1%):
By age:
0-4: 5 (<1%);
l5-17: 25 (1%);
18-64: 2,002 (88%);
65+: 240 (11%);
Missing: 2 (<1%).
By insurance status:
Medicaid or LaCHIP: 263 (12%);
Medicare: 161 (7%);
Private: 145 (6%);
Uninsured: 1,702 (75%);
Other[C]: 1 (<1%);
Missing: 1 (<1%).
Source: GAO analysis of Louisiana Public Health Institute’s (LPHI)
summary of data reported by PCASG fund recipients.
Notes: These data were collected by LPHI from the 25 PCASG fund
recipients. Percentages do not total to 100 percent due to rounding. In
addition to the PCASG funds, all of these recipients have used other
funds to provide services.
[A] An encounter is an interaction between a patient and a provider for
the purpose of meeting a health care need. It can occur by telephone or
in person.
[B] The data on medical and dental encounters are combined; the number
of dental encounters was small.
[C] "Other" includes patients who were in different insurance
categories for two or more encounters, such as patients who were
uninsured at the time of the first encounter and were Medicaid
beneficiaries at the time of the second encounter.
[End of figure]
[End of section]
Appendix III: GAO Contact and Staff Acknowledgments:
GAO Contact:
Cynthia A. Bascetta, 202-512-7114 or bascettac@gao.gov:
Acknowledgments:
In addition to the person named above, Helene F. Toiv, Assistant
Director; Martha R. W. Kelly; Carolyn Feis Korman; Deitra Lee; Roseanne
Price; Dan Ries; Jennifer Whitworth; Rasanjali Wickrema; and Malissa
Winograd made key contributions to this report.
[End of section]
Related GAO Products:
Hurricane Katrina: Barriers to Mental Health Services for Children
Persist in Greater New Orleans, Although Federal Grants Are Helping to
Address Them. [hyperlink, http://www.gao.gov/products/GAO-09-563].
Washington, D.C.: July 13, 2009.
Disaster Assistance: Greater Coordination and an Evaluation of
Programs' Outcomes Could Improve Disaster Case Management. [hyperlink,
http://www.gao.gov/products/GAO-09-561]. Washington, D.C.: July 8,
2009.
Catastrophic Disasters: Federal Efforts Help States Prepare for and
Respond to Psychological Consequences, but FEMA's Crisis Counseling
Program Needs Improvements. [hyperlink,
http://www.gao.gov/products/GAO-08-22]. Washington, D.C.: February 29,
2008.
Hurricane Katrina: Allocation and Use of $2 Billion for Medicaid and
Other Health Care Needs. [hyperlink,
http://www.gao.gov/products/GAO-07-67]. Washington D.C.: February 28,
2007.
Hurricane Katrina: Status of Hospital Inpatient and Emergency
Departments in the Greater New Orleans Area. [hyperlink,
http://www.gao.gov/products/GAO-06-1003]. Washington, D.C.: September
29, 2006.
Hurricane Katrina: Status of the Health Care System in New Orleans and
Difficult Decisions Related to Efforts to Rebuild It Approximately 6
Months after Hurricane Katrina. [hyperlink,
http://www.gao.gov/products/GAO-06-576R]. Washington, D.C.: March 28,
2006.
Hurricane Katrina: GAO's Preliminary Observations Regarding
Preparedness, Response, and Recovery. [hyperlink,
http://www.gao.gov/products/GAO-06-442T]. Washington, D.C.: March 8,
2006.
Mental Health Services: Effectiveness of Insurance Coverage and Federal
Programs for Children Who Have Experienced Trauma Largely Unknown.
[hyperlink, http://www.gao.gov/products/GAO-02-813]. Washington, D.C.:
August 22, 2002.
[End of section]
Footnotes:
[1] Hurricane Katrina made landfall on August 29, 2005. Hurricane Rita
made landfall on September 24, 2005, and caused additional damage to
the greater New Orleans area.
[2] In this report, we define primary care as basic medical care that
is generally provided in an outpatient setting such as a clinic or
general practitioner's office, as opposed to in a hospital.
[3] Medicaid is a federal-state health insurance program for certain
low-income individuals.
[4] Henry J. Kaiser Family Foundation, New Orleans Three Years after
the Storm: The Second Kaiser Post-Katrina Survey, 2008 (August 2008);
and David Abramson, et al., "Prevalence and Predictors of Mental Health
Distress Post-Katrina: Findings from the Gulf Coast Child and Family
Health Study," Disaster Medicine and Public Health Preparedness, vol.
2, no. 2 (2008), 77-86.
[5] This grant was made under a provision of the Deficit Reduction Act
of 2005 authorizing payments to restore access to health care in
communities affected by Hurricane Katrina. Pub. L. No. 109-171, §
6201(a)(4), 120 Stat. 4, 133 (2006). Notice of Single Source Grant
Award, 72 Fed. Reg. 51,230 (Sept. 9, 2007).
[6] In this report, we define mental health care services to include
substance abuse prevention and treatment services.
[7] March 20, 2008, was the end date of the first period for which
recipients of PCASG funds reported data on their activities to LPHI. In
this report, we describe the data for this period at the recipient
level. As of December 2008, the 25 PCASG fund recipients were operating
91 sites that were eligible to use those funds.
[8] For the PCASG, CMS defines sustainability as the ability to
continue to provide primary care to all patients (regardless of their
ability to pay) through some funding mechanism other than the PCASG
funds, such as enrolling as a provider in Medicaid or another public or
private insurer. PCASG funds, which were given only to the state of
Louisiana, were made available to Louisiana for a 3-year period, from
July 23, 2007, through September 30, 2010.
[9] FEMA administers the CCP through an annual interagency agreement
with SAMHSA.
[10] In this report, we define the greater New Orleans area in the same
way CMS does for PCASG purposes--Jefferson, Orleans, Plaquemines, and
St. Bernard parishes.
[11] An encounter is an interaction between a patient and provider for
the purpose of meeting a health care need. An encounter can occur in
person or by telephone.
[12] We have previously reported on HRSA's Health Center Program. See
GAO, Health Centers: Competition for Grants and Efforts to Measure
Performance Have Increased, [hyperlink,
http://www.gao.gov/products/GAO-05-645] (Washington, D.C.: July 13,
2005), and Health Resources and Services Administration: Many
Underserved Areas Lack a Health Center Site, and the Health Center
Program Needs More Oversight, [hyperlink,
http://www.gao.gov/products/GAO-08-723] (Washington, D.C.: Aug. 8,
2008).
[13] 2007 La. Acts 243, codified at LA. REV. STAT. ANN. §§ 46.978 - 979
(2009).
[14] Louisiana Health Care Redesign Collaborative, Concept Paper for a
Redesigned Health Care System for Region 1 (Baton Rouge, La.: 2006).
[15] LaCHIP is the name of Louisiana's State Children's Health
Insurance Program. The State Children's Health Insurance Program is a
federal-state health insurance program that offers insurance to certain
children under age 19 whose family income is too high for Medicaid
eligibility and who are not enrolled under other health insurance.
[16] States operate and administer their Medicaid programs
independently within federal requirements established in statute and
regulations, and the federal government shares in the cost of each
state's program by paying an established share of states' reported
expenditures. Section 1115 of the Social Security Act, however,
authorizes HHS to waive compliance with certain federal statutory
requirements, as well as to authorize costs that would not otherwise be
included as Medicaid expenditures, for demonstrations HHS determines
are likely to promote Medicaid objectives, allowing states to apply to
test and evaluate new approaches for delivering Medicaid services.
[17] Additional CCP funds were distributed elsewhere in Louisiana. In
December 2008, Louisiana was awarded an additional $2.8 million in CCP
funds to cover the costs of services provided in the 2 months following
Hurricane Gustav, which made landfall in Louisiana on September 1,
2008.
[18] SSBG supplemental funds were appropriated to HHS for expenses
related to the 2005 hurricanes under the Department of Defense,
Emergency Supplemental Appropriations to Address Hurricanes in the Gulf
of Mexico, and Pandemic Influenza Act, 2006 (Pub. L. No. 109-148, div.
B, title I, ch. 6, 119 Stat. 2680, 2768 (2005)), which specified that
the funds could be used for health services, including mental health,
as well as for repairs, renovations, and construction of health
facilities. Additional SSBG supplemental funds were appropriated to HHS
in the Consolidated Security, Disaster Assistance, and Continuing
Appropriations Act, 2009 (Pub. L. No. 110-329, div. B, title I, ch. 7,
122 Stat. 3574, 3594-95 (2008)), for expenses related to the 2008
natural disasters and Hurricanes Rita and Katrina. In January 2009,
Louisiana was awarded an additional $129.7 million from these funds.
[19] The period of time these funds are available for expenditure by
states was extended through the end of fiscal year 2009 by the U.S.
Troop Readiness, Veterans' Care, Katrina Recovery, and Iraq
Accountability Appropriations Act, 2007. Pub. L. No. 110-28, § 4702,
121 Stat.112, 160.
[20] LDHH's Office of Mental Health, Office of Addictive Disorders, and
Office for Citizens with Developmental Disabilities provide services in
some parts of the state through regional human services districts. An
LDHH official told us that the human services districts allow for local
control, involvement, and plans based on the unique needs in each
region.
[21] The Secretary of HHS initially awarded the state of Louisiana $15
million for the Hurricane Katrina Healthcare Related Professional
Workforce Supply Grant in March 2007. A supplement of $35 million was
awarded in June 2007. These awards were made under the authority of the
Deficit Reduction Act of 2005. Pub. L. No. 109-171, § 6201(a)(4), 120
Stat. 4, 133 (2006).
[22] According to CMS, health care professionals whose services could
be supported with grant funds could include pediatricians, internists,
family practitioners, obstetricians, psychiatrists, dentists,
registered nurses, nurse practitioners, physician assistants, and other
licensed health care providers and professionals.
[23] The Deficit Reduction Act of 2005 appropriated $2 billion for
these Hurricane Katrina-related activities. We have previously reported
on the allocation of funds under the Deficit Reduction Act of 2005. See
GAO, Hurricane Katrina: Allocation and Use of $2 Billion for Medicaid
and Other Health Care Needs, [hyperlink,
http://www.gao.gov/products/GAO-07-67] (Washington, D.C.: Feb. 28,
2007).
[24] CMS, in collaboration with officials from other HHS agencies,
including HRSA and SAMSHA, had developed guidance that helped LDHH and
LPHI to identify potential applicants for funds from Louisiana; 35
provider organizations in the greater New Orleans area applied for
PCASG funds.
[25] Other requirements were that the organization must establish a
system to collect and organize patient and encounter data and report
the data to LDHH through LPHI, and provide plans if the organization
intends to relocate or renovate health care sites.
[26] Initial disbursements for 24 PCASG fund recipients were calculated
on the basis of operating costs resulting from the number of full-time-
equivalent health care providers working for the organization at the
time it applied for PCASG funds. These PCASG fund recipients received
disbursements that ranged from a minimum of $239,950 to a maximum of
$719,849, which was the funding cap. The other recipient, the New
Orleans Health Department, received $4 million to be used to increase
clinical services; recruit physicians, dentists, registered nurses, and
other licensed professional health care staff for two new sites; and
staff dental and vision care mobile vans. The initial disbursement
awarded to the New Orleans Health Department was not calculated using
the formula used to determine the initial disbursements for the other
PCASG fund recipients because the grant specifically included $4
million for the City of New Orleans Health Department.
[27] Each supplemental disbursement is calculated on the basis of the
recipient's patient count for the relevant time period. The patient
count is weighted on the basis of the patient's age and insurance
status and the type of services provided. The 25 PCASG fund recipients
received supplemental disbursements in December 2007, June 2008, and
December 2008. As of December 2008, the total amount of PCASG funds
disbursed to recipients was more than $62 million.
[28] The evaluation will assess the progress made in creating a network
of primary care "medical homes" at the neighborhood level, evaluate
improvements in access to primary care, and estimate health system
costs (in a medical home model, a patient's care is managed and
coordinated by a personal physician). The expected date of publication
was not available as of June 2009.
[29] According to a CMS official, PCASG funding could be used to open
new sites in existing buildings or structures but could not be used for
construction of a new building.
[30] Proposals for renovation are generally reviewed by LPHI and LDHH.
CMS must approve renovation plans that cost more than $150,000.
[31] Evidence-based standards of care incorporate treatments and
services for which effectiveness is well documented.
[32] The SSBG supplemental funds were distributed before organizations
received PCASG funds. Dollar amounts reflect funds expended by PCASG
fund recipients at sites where they later used PCASG funds.
[33] SSBG supplemental grant funds are available to recipients until
September 2009.
[34] LSU Health Sciences Center New Orleans includes the school of
medicine and provides direct health care as part of its educational
mission.
[35] LDSS gave additional funds to LSU Health Care Services Division
and to Tulane University; however, these funds were not spent at sites
where these PCASG fund recipients used PCASG funds.
[36] MHSD serves Orleans, Plaquemines, and St. Bernard parishes, and
JPHSA serves Jefferson Parish.
[37] None of the contracts were awarded to other PCASG fund recipients.
[38] Behavioral health is a term often used to refer to mental health
and substance abuse services.
[39] Assertive community treatment is a team treatment approach
designed to provide comprehensive, community-based psychiatric
treatment, rehabilitation, and support to persons with serious and
persistent mental illness, such as schizophrenia.
[40] Crisis intervention is immediate, short-term help to individuals
who experienced an event that produced emotional, mental, physical, and
behavioral distress or problems. It aims to reduce the intensity of an
individual's emotional, mental, physical, and behavioral reactions to a
crisis or to help individuals return to their level of functioning
before the crisis.
[41] Mobile crisis intervention is help that is available 24 hours a
day to adults and children with mental illness, an addictive disorder,
or a developmental disability.
[42] In discussing the incentive payments made from Professional
Workforce Supply Grant funds, the information we provide about the 25
PCASG fund recipients is based on the more than 80 sites that were also
eligible to use PCASG funds as of August 2008. Additional health care
providers who have received incentives may be employed by PCASG fund
recipients, but not at sites eligible to use PCASG funds.
[43] Incentive payments were distributed to individual health care
providers as one-time, lump sum payments based on the incentive option
chosen by the provider, including student loan repayment, 1 year's
malpractice insurance premium, sign-on bonus, income guarantee for 1
year, continuing education expenses, and relocation expenses. The
maximum allowable amounts varied by type of provider and incentive
option.
[44] The survey was conducted with all individuals receiving
Professional Workforce Supply Grant incentives and did not present
results separately for those individuals employed at PCASG recipient
organizations.
[45] According to program officials, Catholic Charities terminated this
relationship because indirect costs were not reimbursable. We
previously reported on the challenges associated with this limitation
and recommended that FEMA revise CCP policy to allow for reimbursement
of indirect costs. See GAO, Catastrophic Disasters: Federal Efforts
Help States Prepare for and Respond to Psychological Consequences, but
FEMA's Crisis Counseling Program Needs Improvements, [hyperlink,
http://www.gao.gov/products/GAO-08-22] (Washington, D.C.: Feb. 29,
2008).
[46] Each time we calculated the proportion of survey respondents that
said a challenge had grown since Hurricane Katrina, we excluded from
the analysis respondents whose response was "no basis to judge/not
applicable."
[47] HPSAs are used to identify geographic areas, population groups, or
facilities facing a shortage of primary care, dental, or mental health
providers.
[48] For additional discussion of the limited availability of mental
health providers, see GAO, Hurricane Katrina: Barriers to Mental Health
Services for Children Persist in Greater New Orleans, Although Federal
Grants Are Helping to Address Them, [hyperlink,
http://www.gao.gov/products/GAO-09-563] (Washington, D.C.: July 13,
2009).
[49] HPSA geographic designation for mental health is based on the
ratio of population to mental health professionals, as well as other
factors, including an unusually high need for mental health services.
[50] The availability of dentists is a problem in general for
underserved populations in the United States. See, for example, A.
Snyder, Increasing Access to Dental Care in Medicaid: Targeted Programs
for Four Populations, a report prepared for the National Academy for
State Health Policy (March 2009); and L.E. Mentasti and E.A. Thibodeau,
"Dental School Applicants by State Compared to Population and Dentist
Workforce Distribution," Journal of Dental Education, vol. 72, no. 11
(2008).
[51] Specialty care referrals are a problem in general for underserved
populations. See, for example, GAO, Health Centers: Competition for
Grants and Efforts to Measure Performance Have Increased, [hyperlink,
http://www.gao.gov/products/GAO-05-645] (Washington, D.C.: July 13,
2005), 28; and J. S. Weissman, et al., "Limits to the Safety Net:
Teaching Hospital Faculty Report on Their Patients' Access to Care,"
Health Affairs, vol. 22, no. 6 (2003).
[52] The American Recovery and Reinvestment Act of 2009 provided HRSA
with $2 billion for the Health Center Program. Pub. L. No. 111-5, div.
A, title VIII, 123 Stat. 115, 175. However, $155 million was used for
New Access Point grants in March 2009, and HRSA plans to use the
remainder to provide various types of grants to existing Health Center
Program grantees.
[53] Through the Ryan White Comprehensive AIDS Resources Emergency Act
of 1990 and subsequent legislation, HRSA provides federal funds to
metropolitan areas, states, and others to assist with the cost of core
medical and support services for individuals and families infected and
affected by HIV/AIDS. See 42 U.S.C. §§ 300ff through 300ff-121.
[54] In this report, we define the greater New Orleans area in the same
way CMS does for PCASG purposes--Jefferson, Orleans, Plaquemines, and
St. Bernard parishes.
[55] An encounter is an interaction between a patient and a provider
for the purpose of meeting a health care need. An encounter can occur
in person or by telephone.
[56] PCASG fund recipients provided data to LPHI for 73 of the 75 sites
eligible to receive PCASG funds during this period. PCASG funds were
not the only funds used to provide the services these data describe.
Although the City of New Orleans Health Department had 4 PCASG-eligible
sites, the department provided data for only 2 of these sites.
[57] To collect uniform data, LPHI provided the recipients with forms
and guidance on completing these forms.
[58] This grant was made under a provision of the Deficit Reduction Act
of 2005 authorizing payments to restore access to health care in
affected communities. Pub. L. No. 109-171, § 6201(a)(4), 120 Stat. 4,
133 (2006). Notice of Single Source Grant Award, 72 Fed. Reg. 51,230
(Sept. 9, 2007).
[59] For PCASG purposes, CMS defined the greater New Orleans area as
Jefferson, Orleans, Plaquemines, and St. Bernard parishes.
[60] Under Section 330 of the Public Health Service Act, HRSA provides
grants to health centers nationwide to increase access to primary care.
[61] September 21, 2007, through March 20, 2008, was the first period
for which PCASG fund recipients reported data on their activities to
LPHI.
[62] Medicaid is a federal-state health insurance program for certain
low-income individuals.
[63] LaCHIP is the name of Louisiana's State Children's Health
Insurance Program. The State Children's Health Insurance Program is a
federal-state health insurance program that offers insurance to certain
children under age 19 whose family income is too high for Medicaid
eligibility and who are not enrolled under other health insurance.
[64] All recipients have used funds other than the PCASG funds to offer
the health care services.
[65] For the period September 21, 2007, through March 20, 2008, PCASG
fund recipients were required by LPHI to provide data about podiatry,
optometry, and tuberculosis therapy specialty care services only.
[66] An encounter is an interaction between a patient and a provider
for the purpose of meeting a health care need. It can occur by
telephone or in person.
[67] LPHI combined the data on medical and dental encounters because
the number of dental care encounters was small.
[End of section]
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